Circulatory and respiratory complications of carbon dioxide insufflation

Laparoscopic cholecystectomy in a patient with Fontan circulation

BACKGROUND

Fontan circulation is created when a baby is born with only one functioning cardiac ventricle. A series of surgeries are performed to allow the ventricle to provide oxygenated blood to the systemic circulation and to create passive flow of venous blood to the pulmonary circulation via a conduit. Laparoscopic surgery poses several hemodynamic challenges to a patient with Fontan physiology attributable to carbon dioxide insufflation, positive pressure ventilation, and reverse Trendelenburg positioning.

CLINICAL FEATURES

A 39-yr-old male with a Fontan physiology was referred to our tertiary care centre because of repeated bouts of cholecystitis requiring a percutaneous drain and now elective laparoscopic cholecystectomy. Because of repeated cardiac surgeries, the patient also had complete heart block and was pacemaker dependent. We placed an arterial catheter prior to induction of general anesthesia with tracheal intubation. Transesophageal echocardiography allowed for real-time intraoperative assessment of venous blood flow through the patient's extracardiac diversion system throughout the surgery. This information was used to guide management and determine circulation tolerance during the various stages of laparoscopy. Inhaled milrinone resulted in the shunt fraction returning to the patient's baseline. Intraperitoneal pressure was kept below 10 mm Hg, and systemic blood pressure was supported with a low-dose norepinephrine infusion.

CONCLUSIONS

Intraoperative transesophageal echocardiography is a useful monitoring device during laparoscopic surgery when a patient has Fontan circulation. Knowing how to administer inhaled milrinone is a useful skill to decrease the shunt fraction through a patient's conduit, increasing pulmonary blood flow while avoiding hypotension.

Pressure Control Ventilation Versus Volume Control Ventilation in Laparoscopic Surgery: A Narrative Review

This review compares the safety and effectiveness of volume control ventilation (VCV) and pressure control ventilation (PCV) during laparoscopic surgery. Nine studies were chosen for in-depth examination following the application of stringent inclusion and exclusion criteria to the 184 publications that the literature search turned up. PCV is well-known for its capacity to preserve lower peak airway pressures during laparoscopic procedures, lowering the risk of volutrauma and barotrauma and enhancing oxygenation under these conditions of elevated intra-abdominal pressures. On the other hand, VCV guarantees a constant tidal volume and offers accurate ventilation management, both of which are essential for preserving stable carbon dioxide levels. VCV, however, may result in higher peak airway pressures, raising the risk of lung damage brought on by a ventilator. Research indicates that PCV provides better respiratory mechanics management during laparoscopic surgery, but VCV consistent tidal volume delivery is useful in some clinical situations. When choosing between PCV and VCV, the anesthesia team's experience, the demands of each patient, and the surgical circumstances should all be taken into consideration. Real-time monitoring tools and sophisticated ventilatory technology are essential for maximizing ventilation techniques. Further improving patient outcomes can be achieved by incorporating multimodal anesthesia approaches, such as the use of muscle relaxants and customized intraoperative fluid management. Muscle relaxants optimize conditions for mechanical ventilation by ensuring adequate muscle relaxation, reducing the risk of ventilator-associated lung injury, and enabling more precise control of ventilation parameters. Tailored intraoperative fluid management helps maintain optimal lung mechanics by avoiding fluid overload, which can lead to pulmonary edema and compromised gas exchange, necessitating adjustments in ventilation strategy. While both ventilation modalities can be utilized efficiently, the research suggests that PCV may be more advantageous in controlling oxygenation and airway pressures. In the dynamic and demanding world of laparoscopic surgery, ongoing research and clinical innovation are crucial to improving these tactics and guaranteeing the best possible treatment. In order to obtain the best possible patient outcomes during laparoscopic surgeries, this review emphasizes the significance of customized breathing techniques.

Laparoscopic versus open distal gastrectomy for advanced gastric cancer in elderly patients: a propensity-score matched analysis

BACKGROUND

Scarce research has reported the efficacy and safety of laparoscopic distal gastrectomy in elderly patients. This retrospective study aimed to compare the outcomes of laparoscopic and open distal gastrectomy for advanced gastric cancer in elderly patients.

METHODS

A total of 303 elderly patients who underwent distal gastrectomy for advanced gastric cancer from June 2017 to June 2021 were enrolled. Variables used to calculate propensity score matching included sex, age, body mass index, American Society of Anesthesiologists, history of diabetes, and history of hypertension. The statistical significance of continuous variables was tested using an independent sample t test. chi-square or Fisher's exact tests were used for categorical variables. Kaplan-Meier curve and log-rank test were used for the evaluation of 3-year overall survival and recurrence-free survival.

RESULTS

After performing 1:1 propensity score matching, 248 patients were included for analysis (laparoscopic = 124, open = 124). Compared with the open group, the laparoscopic group showed significant advantages in estimated blood loss (P < 0.001), pain scale on the first postoperative day (P = 0.002), time to first flatus (P = 0.004), time to first liquid diet (P = 0.005), hospital stays (P < 0.001), and total complications (P = 0.011), but devoted much more operation time (P < 0.001). No statistical difference was observed between the two groups in 3-year recurrence-free survival (P = 0.315) or overall survival (P = 0.159).

CONCLUSIONS

Our analysis demonstrated that laparoscopic surgery had the advantages of less intraoperative blood loss, fewer postoperative complications, and faster postoperative recovery in distal gastrectomy for advanced gastric, indicating that laparoscopic distal gastrectomy is safe and effective for treating elderly patients with distal gastric cancer.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Ventricular tachycardia and acute heart failure induced by atropine in the treatment of bradycardia: A case report and literature review

RATIONALE

Despite various advantages of laparoscopic surgical procedures, artificial pneumoperitoneum might lead to hemodynamic fluctuations including severe bradycardia and cardiac arrest. Atropine is usually proposed to treat intraoperative severe bradycardia ( < 40 beats per minute). However, atropine could induce ventricular arrhythmias, which might be life-threatening in severe case.

PATIENT CONCERNS

Here, we reported a 41-year-old female who was diagnosed with gallbladder polyps and was scheduled for laparoscopic cholecystectomy under general anesthesia.

DIAGNOSES

Bradycardia occurred suddenly during the operation and atropine was injected intravenously. Eventually the patient developed ventricular tachycardia and acute heart failure.

INTERVENTIONS

We organized an urgent consultation and the patient was treated immediately.

OUTCOMES

Fortunately, the patient experienced no complications after timely diagnosis and treatment. After 6 months of follow-up, her New York Heart Association classification was I with no complications.

LESSONS

This case highlighted that the administration of atropine to treat bradycardia may lead to ventricular tachycardia and acute heart failure, and anesthesiologists should remain vigilant to avoid potentially life-threatening consequences.

Pneumoperitoneum and Acute Kidney Injury-An Integrative Clinical Concept Review

An increased intraabdominal pressure, particularly when occurring during periods of hemodynamic instability or fluid overload, is regarded as a major contributor to acute kidney injury (AKI) in intensive care units. During abdominal laparoscopic procedures, intraoperative insufflation pressures up to 15 mmHg are applied, to enable visualization and surgical manipulation but with the potential to compromise net renal perfusion. Despite the widely acknowledged renal arterial autoregulation, net arterial perfusion pressure is known to be narrow, and the effective renal medullary perfusion is disproportionately impacted by venous and lymphatic congestion. At present, the potential risk factors, mitigators and risk-stratification of AKI during surgical pneumoperitoneum formation received relatively limited attention among nephrologists and represent an opportunity to look beyond mere blood pressure and intake-output balances. Careful charting and reporting duration and extent of surgical pneumoperitoneum represents an opportunity for anesthesia teams to better communicate intraoperative factors affecting renal outcomes for the postoperative clinical teams. In this current article, the authors are integrating preclinical data and clinical experience to provide a better understanding to optimize renal perfusion during surgeries. Future studies should carefully consider intrabdominal insufflation pressure as a key variable when assessing outcomes and blood pressure goals in these settings.

Automated control for investigation of the insufflation-ventilation interaction in experimental laparoscopy

In laparoscopic surgery the abdominal cavity is insufflated with pressurized carbon dioxide gas to create workspace. This pressure is exerted through the diaphragm onto the lungs, competing with ventilation and hampering it. In clinical practice the difficulty of optimizing this balance can lead to the application of harmfully high pressures. This study set out to create a research platform for the investigation of the complex interaction between insufflation and ventilation in an animal model. The research platform was constructed to incorporate insufflation, ventilation and relevant hemodynamic monitoring devices, controlling insufflation and ventilation from a central computer. The core of the applied methodology is the fixation of physiological parameters by applying closed-loop control of specific ventilation parameters. For accurate volumetric measurements the research platform can be used in a CT scanner. An algorithm was designed to keep blood carbon dioxide and oxygen values stable, minimizing the effect of fluctuations on vascular tone and hemodynamics. This design allowed stepwise adjustment of insufflation pressure to measure the effects on ventilation and circulation. A pilot experiment in a porcine model demonstrated adequate platform performance. The developed research platform and protocol automation have the potential to increase translatability and repeatability of animal experiments on the biomechanical interactions between insufflation and ventilation.

Detection of carbon dioxide embolism by transesophageal echocardiography during transanal/perineal endoscopic surgery: a pilot study

The transanal/perineal (ta/tp) endoscopic approach has been widely used for anorectal surgery in recent years, but carbon dioxide embolism is a possible lethal complication. The frequency of this complication in this approach is not known. In this study, we investigated the frequency of intraoperative (including occult) carbon dioxide embolism using transesophageal echocardiography. Patients who underwent surgery via the ta/tp approach and consented to participate were included. Intraoperative transesophageal echocardiography was used to observe the right ventricular system in a four-chamber view. Changes in end-tidal carbon dioxide (EtCO₂), oxygen saturation (SpO₂), and blood pressure were taken from anesthesia records. Median maximum insufflation pressure during the ta/tp approach was 13.5 (12-18) mmHg. One patient (4.8%) was observed to have a bubble in the right atrium on intraoperative transesophageal echocardiography, with a decrease in EtCO₂ from 39 to 35 mmHg but no obvious change in SpO₂ or blood pressure. By lowering the insufflation pressure from 15 to 10 mmHg and controlling bleeding from the veins around the prostate, the gas rapidly disappeared and the operation could be continued. Among all patients, the range of variation in intraoperative EtCO₂ was 5-22 mmHg, and an intraoperative decrease in EtCO₂ of > 3 mmHg within 5 min was observed in 19 patients (median 5 mmHg in 1-10 times).Clinicians should be aware of carbon dioxide embolism as a rare but potentially lethal complication of anorectal surgery, especially when using the ta/tp approach.

Short Term Outcomes of Open and Minimally Invasive Approaches to Segmental Colectomy for Benign Colovesical Fistula

Background. We speculated that a minimally invasive (MIS) colectomy for colovesical fistula is associated with less morbidity compared to an open colectomy. Methods. Multivariate analysis using logistic regression was used to investigate the outcomes of patients who underwent colectomy for benign colovesical fistula during 2012–2017 by surgical approach using the NSQIP database. Results. We identified 748 patients underwent partial colectomy for benign colovesical fistula during 2012–2017. Surgeons used the MIS approach in 72.7% of operations, with a conversion rate of 13.1%. The MIS approach was associated with lower morbidity (27.4% vs. 43.1%, AOR: 0.46, $P=0.02$ ) compared to the open approach. The mean operation duration was longer in MIS operations compared to open (225 min vs. 201 min, $P<0.01$ ). The robotic approach to colectomy showed no significant difference in morbidity (28.4% vs. 27.2%, $P=0.77$ ) but a decrease in conversion rate (8.1% vs. 13.8%, $P<0.01$ ) and an increase in operation length (249 min vs. 222 min, mean difference: 27 min, $P<0.01$ ) compared to a laparoscopic approach. There was no significant difference in the anastomotic leak rate between MIS and open approaches (3.7% vs. 5.4%, $P=0.14$ ) and between laparoscopic and robotic approaches (2.8% vs. 3.8%, $P=0.99$ ). Conclusions. We found a 72.7% utilization rate of MIS approach to colectomy for benign colovesical fistula in the NSQIP hospitals with a 13.6% conversion rate. Patients with MIS approach had significantly lower morbidity compared to open. A robotic approach to partial colectomy has the same morbidity risk with a decreased conversion rate compared to laparoscopic approach.

Laparoscopic versus open distal gastrectomy for elderly patients with advanced gastric cancer: a retrospective comparative study

BACKGROUND

Laparoscopic radical distal gastrectomy (LDG) has been more frequently performed for locally advanced distal gastric cancer (AGC) than open distal gastrectomy (ODG). However, the benefits of LDG for elderly AGC patients (AGC-lap) remain unclear.

METHODS

Patients aged ≥ 70 years who underwent D2 distal gastrectomy from July 2014 to July 2021 were enrolled consecutively. Perioperative parameters, pathological features, and oncological outcomes of AGC-lap patients (n = 39) were compared with those of elderly AGC patients receiving ODG (AGC-open; n = 37) and elderly early gastric cancer patients receiving LDG (EGC-lap; n = 41) respectively.

RESULTS

The median age of all AGC patients was 77 years, and 28% of them had an Eastern Cooperative Oncology Group score ≥ 2. Most of the perioperative and pathological features (including the number of lymph nodes harvested) were similar between the AGC-lap and AGC-open groups. AGC-lap patients had longer median operative times (215 min versus 192 min) but significantly less surgical complications (10.3% versus 37.8%) and shorter median hospital stays (11 days versus 13 days) than did AGC-open patients (all p < 0.05). The 3-year recurrence-free and overall survival was 66.2% and 88.8% in the AGC-lap group and 51% and 66.3% in the AGC-open group (both p = 0.1). The perioperative features, including operative time, number of lymph nodes harvested, hospital stay, and complication rates, were similar between the AGC- and EGC-lap groups.

CONCLUSIONS

LDG was safely and effectively performed in elderly AGC patients, resulting in faster recovery and a lower complication rate than ODG, without compromising oncological outcomes.

Hemodynamic derangement associated with tension pneumomediastinum during minimally invasive esophagectomy: A case report

RATIONALE

Surgery is the treatment of choice for esophageal cancer. Since the 1990s, minimally invasive esophagectomy (MIE) has been developed using videoscope. Although MIE lowers mortality by reducing postoperative complications, the risk of carbon dioxide (CO2) insufflation related complications still exists.

PATIENT CONCERNS

A 56-years-old male patient underwent elective MIE. The patient (body mass index, 15 kg/m2) had well-controlled hypertension, cardiomegaly, and severe emphysematous lungs. He had iatrogenic pneumothorax during central venous catheterization 3 weeks prior; however, the pneumothorax was resolved before surgery.

DIAGNOSIS

During thoracoscopic surgery, respiratory acidosis was not corrected despite rapid respiratory rate and positive end-expiratory pressure. Intrathoracic CO2 pressure was lowered from 12 to 8 mm Hg, and laparoscopic surgery was performed through the diaphragm in the reverse Trendelenburg position. In 15 minutes at this position, pulseless electrical activity with respiratory failure and high peak inspiratory pressure developed.

INTERVENTIONS

CO2 insufflation was stopped and drained as soon as hypotension developed. The patient was placed in the supine neutral position, and cardiopulmonary circulation was restored without further treatment.

OUTCOMES

After the pneumomediastinum event, surgery was successfully performed. Respiratory acidosis due to CO2 insufflation was not corrected during surgery and the patient was transferred to intensive care unit without extubation. After 14 days, the patient was discharged without cardiopulmonary complications. However, the patient expired 2 years later due to cardiovascular disease.

LESSONS

In MIE, there is always a risk of catastrophic tension pneumomediastinum along with intravascular volume depletion, surgical position, and ventilatory strategy depending on the surgical characteristics.

Impact of lidocaine on hemodynamic and respiratory parameters during laparoscopic appendectomy in children

We assessed the influence of systemic lidocaine administration on ventilatory and circulatory parameters, and the pneumoperitoneum impact on the cardiopulmonary system during a laparoscopic appendectomy in children. A single-center parallel single-masked randomized controlled study was carried out with 58 patients (3-17 years). Intravenous lidocaine bolus of 1.5 mg/kg over 5 min before induction of anesthesia followed by lidocaine infusion at 1.5 mg/kg/h intraoperatively. Respiratory system compliance (C, C/kg), P_peak-PEEP and Pulse rate (Pulse), systolic, diastolic and mean blood pressure (NBP_s, NBP_d, NBP_m), assessed in the Lidocaine and Control group, at the: beginning (P₁), minimum lung compliance (P₂) and at the end of surgery (P₃) were compared. The respiratory/hemodynamic parameters did not differ between the groups at any stage of operation. Blood Pressure and P_peak-PEEP were significantly higher at the P₂ compared to P₁ and P₃ stages (P < 0.001, 1 - β ≥ 0.895) that correlated with lung compliance changes: C/kg vs. NBP_s and P_peak-PEEP (- 0.42, - 0.84; P < 0.001); C vs. Pulse and P_peak-PEEP (- 0.48, - 0.46; P < 0.001). Although an increase in intraabdominal pressure up to 12(15) mmHg causes significant changes in hemodynamic/respiratory parameters, there appears to be no risk of fatal reactions in 1E, 2E ASA patients. Systemic lidocaine administration doesn't alleviate circulatory/respiratory alterations during pneumoperitoneum. No lidocaine related episode of anaphylaxis, systemic toxicity, circulatory disturbances or neurological impairment occurred.ClinicalTrials.gov: 22/03/2019.Trial registration number: NCT03886896.

Risk factors of postoperative septic cardiomyopathy in perioperative sepsis patients

Objective

This study aimed to clarify the relevant risk factors of septic cardiomyopathy (SCM) in perioperative sepsis patients.

Methods

This retrospective study evaluated patients who were diagnosed with sepsis during the perioperative period and postoperatively admitted to the intensive care unit (ICU) in the Second Affiliated Hospital of Soochow University, the First Affiliated Hospital of Soochow University, and the Suzhou Municipal Hospital between January 2017 and November 2020. They were divided into two groups as the septic cardiomyopathy group (SCM group) and the non-SCM group (NSCM group). Factors with P < 0.1 were compared between groups and were analyzed by multivariate logistic regression to screen the risk factors of sepsis cardiomyopathy. The area under the receiver operating characteristic (ROC) curve was used to verify the discriminative ability of multivariate logistic regression results. Hosmer-Lemeshow goodness of fit test was used to verify the calibration ability of multiple logistic regression results.

Result

Among the 269 patients, 49 patients had SCM. Sequential Organ Failure Assessment (SOFA) score (adjusted odds ratio [AOR] = 2.535, 95% confidence interval (CI): 1.186-1.821, P = 0.000]) and endoscopic surgery (AOR = 3.154, 95% CI: 1.173-8.477, P = 0.023]) were identified to be independent risk factors for SCM. Patients with a SOFA score ≥ 7 had a 46.831-fold higher risk of SCM (AOR =46.831, 95% CI: 10.511-208.662, P < 0.05). The multivariate logistic regression results had good discriminative (area under the curve: 0.902 [95% CI: 0.852-0.953]) and calibration (c² = 4.401, P = 0.819) capabilities. The predictive accuracy was 86.2%. The rates of mechanical ventilation and tracheotomy were significantly higher in the SCM group than in the NSCM group (both P < 0.05). The SCM group also had a significantly longer duration of mechanical ventilation (P < 0.05) and significantly higher rates of continuous renal replacement therapy (CRRT) and CRRT-related mortality (P < 0.05). Further, the total length of stay and hospitalization cost were significantly higher in the SCM group than in the NSCM group (P < 0.05).

Conclusion

Endoscopic surgery and SOFA score ≥ 7 during postoperative ICU admission were independent risk factors for SCM within 48 hours postoperatively in patients with perioperative sepsis.

Single-Port Transaxillary Robot-Assisted Latissimus Dorsi Muscle Flap Reconstruction for Poland Syndrome: Concomitant Application of Robotic System to Contralateral Augmentation Mammoplasty

Currently, robot-assisted latissimus dorsi muscle flap (RLDF) surgery is used in treating patients with Poland syndrome and for breast reconstruction. However, conventional RLDF surgery has several inherent issues. We resolved the existing problems of the conventional system by introducing the da Vinci single-port system in patients with Poland syndrome. Overall, three patients underwent RLDF surgery using the da Vinci single-port system with gas insufflation. In the female patient, after performing RLDF with silicone implant, augmentation mammoplasty was also performed on the contralateral side. Both surgeries were performed as single-port robotic-assisted surgery through the transaxillary approach. The mean operating time was 449 (335–480) minutes; 8.67 (4–14) minutes were required for docking and 59 (52–67) minutes for robotic dissection and LD harvesting. No patients had perioperative complication and postoperative problems related to gas inflation. The single-port robot-assisted surgical system overcomes the drawbacks of previous robotic surgery in patients with Poland syndrome, significantly shortens the procedure time of robotic surgery, has superior cosmetic outcomes in a surgical scar, and improves the operator's convenience. Furthermore, concurrent application to another surgery demonstrates the possibility in the broad application of the robotic single-port surgical system.

Dysautonomia following breast surgery: Disproportionate response to post-operative hematoma

Background

Up to 10% of patients undergoing breast surgery suffer from bleeding complications. Some experience severe hypotension and bradycardia of unclear etiology. Similar to the vasovagal hyperstimulation provoked by abdominal insufflation during laparoscopic surgery, we hypothesize that chest wall stretch from postoperative breast hematoma may mechanically stretch the vagus nerve, triggering dysautonomia disproportionate to the degree of blood loss.

Methods

A single-institution retrospective review of patients requiring reoperation for hematoma evacuation following breast surgery between 2011 and 2021 was performed. The relationship between hematoma volume and hemodynamic instability, as well as hematoma volume and vasovagal symptoms, was measured.

Results

Sixteen patients were identified. Average hematoma volume was 353 mL, and average minimum mean arterial pressure was 64 mm Hg (range: 34–102 mm Hg). Fifty-six percent of patients reported symptoms including dizziness, somnolence, and/or syncope. Accounting for body surface area, patients with larger hematomas had similar minimum mean arterial pressures compared to those with smaller hematomas, 55 and 73 mm Hg, respectively (P = .0943). However, patients in the large hematoma group experienced over 3 times as many vasovagal symptoms, 88% and 25%, respectively (P = .0095).

Conclusion

Patients with large hematomas reported significantly more vagal symptoms compared to those with small hematomas despite similar mean arterial pressures. In addition, the trend of lower mean arterial pressures and heart rates more closely resembles vagal hyperstimulation than hypovolemic shock. Early hematoma evacuation to relieve vagal nerve stretch and parasympatholytics to reverse dysautonomia are targeted interventions to consider in this patient population rather than fluids, vasopressors, and blood products that are used in cases of hemodynamic instability due to hypovolemia alone.

Preoperative Dexmedetomidine and intraoperative bradycardia in laparoscopic cholecystectomy: meta-analysis with trial sequential analysis

Background

While laparoscopic surgical procedures have various advantages over traditional open techniques, artificial pneumoperitoneum is associated with severe bradycardia and cardiac arrest. Dexmedetomidine, an imidazole derivative that selectively binds to α²-receptors and has sedative and analgesic properties, can cause hypotension and bradycardia. Our primary aim was to assess the association between dexmedetomidine use and intraoperative bradycardia during laparoscopic cholecystectomy.

Methods

We performed a systematic review with a meta-analysis and trial sequential analysis using the following PICOS: adult patients undergoing endotracheal intubation for laparoscopic cholecystectomy (P); intravenous dexmedetomidine before tracheal intubation (I); no intervention or placebo administration (C); intraoperative bradycardia (primary outcome), intraoperative hypotension, hemodynamics at intubation (systolic blood pressure, mean arterial pressure, heart rate), dose needed for induction of anesthesia, total anesthesia requirements (both hypnotics and opioids) throughout the procedure, and percentage of patients requiring postoperative analgesics and experiencing postoperative nausea and vomiting and/or shivering (O); randomized controlled trials (S).

Results

Fifteen studies were included in the meta-analysis (980 patients). Compared to patients that did not receive dexmedetomidine, those who did had a higher risk of developing intraoperative bradycardia (RR: 2.81, 95% CI [1.34, 5.91]) and hypotension (1.66 [0.92, 2.98]); however, they required a lower dose of intraoperative anesthetics and had a lower incidence of postoperative nausea and vomiting. In the trial sequential analysis for bradycardia, the cumulative z-score crossed the monitoring boundary for harm at the tenth trial.

Conclusions

Patients undergoing laparoscopic cholecystectomy who receive dexmedetomidine during tracheal intubation are more likely to develop intraoperative bradycardia and hypotension.

Effects of different intraabdominal pressures on internal jugular vein, liver and kidney functions in obese patients undergoing laparoscopic sleeve gastrectomy

OBJECTIVE

The aim of this study was to investigate whether there was a difference in laparoscopic sleeve gastrectomy (LSG) performed with either 10 mmHg or 13 mmHg intraabdominal pressures. Effects of these pressures on the internal jugular vein (IJV) diameter and flow along with the liver and kidney function tests were evaluated.

MATERIALS AND METHODS

The patients were divided into two groups with respect to the intraabdominal pressure performed during LSG (either 10 or 13 mmHg). The patients' age, comorbidities, surgical history, height, weight, body mass index, family history, duration of surgery, length of hospital stay, serum liver and kidney function tests (Urea, creatinine, Aspartate transaminase, Alanine transaminase, Gamma-glutamyltransferase, Alkaline phosphatase, bilirubin) and the right IJV diameter and flow measured by Duplex ultrasound before intubation (t1), 10 min after insufflation (t2), and at the end of insufflation (t3) were recorded.

RESULTS

Preoperative and postoperative kidney and liver function values of the patients in both groups were within the reference range. In both groups, there was a significant decrease in the IJV diameter and flow measurement values at t2 compared to t1, and a significant increase was observed at t3 compared to t2 (p < 0.05). The mean IJV diameter and flow were significantly higher in the 10 mmHg pressure group compared to the 13 mmHg group (p < 0.05).

CONCLUSION

Neither of the peak pressures performed intraabdominal during LSG caused an adverse effect on liver or kidney functions. Our study emphasizes that low insufflation pressure does not have an advantage in terms of liver and kidney functions. But laparoscopic sleeve gastrectomy with low intra-abdominal pressure may be beneficial especially in patients who require central vein catheterization during the operation. We consider that LSG performed with CO₂ pneumoperitoneum at 10 mmHg is a safe, effective and feasible method that can facilitate the insertion of the intraoperative central venous catheter due to lesser charges in the IJV diameter and flow compared to the standard technique.

Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review

A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”.

Obesity and anesthetic pharmacology: simulation of target-controlled infusion models of propofol and remifentanil

The prevalence of obesity is increasing, resulting in an increase in the number of surgeries performed to treat obesity and diseases induced by obesity. The associated comorbidities as well as the pharmacokinetic and pharmacodynamic changes that occur in obese patients make it difficult to control the appropriate dose of anesthetic agents. Factors that affect pharmacokinetic changes include the increase in adipose tissue, lean body weight, extracellular fluid, and cardiac output associated with obesity. These physiological and body compositional changes cause changes in the pharmacokinetic and pharmacodynamic parameters. The increased central volume of distribution and alterations in the clearance of drugs affect the plasma concentration of propofol and remifentanil in the obese population. Additionally, obesity can affect pharmacodynamic properties, such as the 50% of maximal effective concentration and the effect-site equilibration rate constant (ke0). Conducting a simulation of target-controlled infusions based on pharmacokinetic and pharmacodynamic models that include patients that are obese can help clinicians better understand the pharmacokinetic and pharmacodynamic changes of anesthetic drugs associated with this population.

Impact of intraoperative hypocapnia on postoperative complications in laparoscopic surgery for colorectal cancer

PURPOSE

In laparoscopic surgery (LS) for colorectal cancer (CRC), the relationship between intraoperative end-tidal carbon dioxide concentration (EtCO₂) and surgery-related complications remains unexplored. This study assessed the impact of intraoperative EtCO₂ on postoperative complications in LS for CRC.

METHODS

In total, 909 patients who underwent LS for CRC were enrolled. Hypocapnia and hypercapnia were defined as EtCO₂ < 35 mmHg and > 40 mmHg, respectively, and the relationships between hypocapnia or hypercapnia duration and postoperative complications were analyzed.

RESULTS

The median (range) durations of hypocapnia and hypercapnia were 2.0 (0-8.3) h and 0.3 (0-5.8) h, respectively. Complications were observed in 208 cases (23.0%), which included 37 (4.1%) instances of anastomotic leakage and 86 (9.5%) of superficial surgical site infection (SSI). While the hypercapnia duration was not associated with the short-term outcomes, prolonged hypocapnia was significantly correlated with complications (p = 0.02), specifically superficial SSI (p = 0.005). Multivariate analyses adjusted for confounding factors confirmed that hypocapnia prolongation was an independent risk factor for postoperative superficial SSI [OR 1.19; 95% confidence interval (Cl) 1.03-1.36, p = 0.01].

CONCLUSION

Intraoperative hypocapnia may be a risk factor for postoperative complications, in particular superficial SSI, in LS for CRC.

Risk Factors for Postoperative Liver Enzyme Elevation After Laparoscopic Gastrectomy for Gastric Cancer

BACKGROUND/AIM

Laparoscopic gastrectomy (LG) is more frequently associated with postoperative liver enzyme elevation (PLEE) than open gastrectomy in phase III clinical trials for Japanese gastric cancer patients. The aim of this study was to determine the risk factors for PLEE after LG for gastric cancer.

PATIENTS AND METHODS

This study enrolled 153 consecutive patients with gastric cancer who underwent LG. The patient characteristics, the liver retraction method [silicone disc (SD) or Nathanson liver retractor (NLR)], and perioperative outcomes were compared between patients with and without PLEE.

RESULTS

PLEE was observed in 26 patients (17%). The patients with PLEE exhibited longer operative times (p=0.005) and more frequent use of the NLR for liver retraction (p=0.022). In the multivariate analysis, liver retraction using the NLR (p=0.003) and aberrant left hepatic artery (ALHA) ligation (p=0.042) were independent risk factors of PLEE.

CONCLUSION

Liver retraction with the SD during LG was shown to be the safer method that is less likely to cause postoperative liver dysfunction. ALHA preservation may contribute to avoiding postoperative liver dysfunction.

Carbon dioxide embolism with severe hypotension as an initial symptom during laparoscopy: a case report

Laparoscopy is widely used because it induces minimal postoperative pain and facilitates rapid recovery. However, carbon dioxide (CO₂) embolism is a rare but potentially fatal complication of laparoscopic surgery. Earlier reports have shown that decreased end-tidal CO₂ (ETCO₂) and increased partial pressure of CO₂ might be useful indicators of CO₂ embolism. We herein report a case of CO₂ embolism after the freed bladder neck was released during laparoscopic radical prostatectomy. Sudden hemodynamic disorder and increased ETCO₂ combined with immediate arterial blood gas analysis led us to suspect CO₂ embolism, which was confirmed by the aspiration of foamy blood from the central venous catheter. The patient was successfully resuscitated and recovered well. This case illustrates that hemodynamic collapse accompanied by increased ETCO₂ can indicate CO₂ embolism.

Laparoscopic Surgery Requiring Abdominal Insufflation in Patients With Congenital Heart Disease

OBJECTIVE

To determine if patients with congenital heart disease are undergoing laparoscopic surgery requiring abdominal insufflation and to compare the outcomes of these procedures with those who underwent an open surgical approach.

DESIGN, SETTING, PARTICIPANTS

This was a retrospective study using the National Inpatient Sample from 2006 to 2014. Individuals with congenital heart disease who underwent at least one of six selected surgical procedures (laparoscopic or open) were included in the study. Subgroup analysis was performed on patients with Fontan palliation.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was to determine the frequency with which congenital heart disease patients undergo laparoscopic surgery requiring abdominal insufflation compared with open surgery. Secondary outcomes included all-cause in-hospital mortality and in-hospital length of stay. Of the 5,527 patients included, nearly half underwent laparoscopic surgery (46.3%), and 128 (2.3%) had single-ventricle circulation. All-cause mortality was significantly higher for those who underwent open surgery compared with the laparoscopic approach (3.6% v 0.9%; odds ratio [OR], 4.0 [2.6-6.3]; p < 0.0001). Subgroup analysis of patients with Fontal palliation older than five years showed 30 (42%) underwent laparoscopic surgery and there was no mortality difference between the laparoscopic and open approaches (OR, 1.4 [0.2-21.3], p = 0.8). Length of stay was significantly shorter for patients undergoing laparoscopic compared with open surgery (median three days [interquartile range, two-five] v six days [three-13], p < 0.0001).

CONCLUSIONS

Individuals with congenital heart disease are being offered laparoscopic surgery that requires abdominal insufflation. All-cause mortality and length of stay were higher for patients who underwent open surgical operations.

A case of sigmoidectomy for sigmoid colon cancer with severe pulmonary arterial hypertension associated with mixed tissue connected disease: A case report

Introduction

Patients with mixed connective tissue disease (MCTD) have higher rates of pulmonary arterial hypertension (PAH) than the general population. PAH is a risk for perioperative respiratory and heart failure, and marked edema of colonic stoma after sigmoidectomy. We report a case of sigmoidectomy for sigmoid colon cancer in a patient with PAH associated with MCTD for whom perioperative treatment was planned to control pulmonary arterial pressure (PAP), and a surgical strategy to avoid complications attributable to PAH and MCTD was employed.

Case presentation

A 52-year-old woman with sigmoid cancer and severe PAH associated with MCTD underwent surgery. We controlled PAH by using intravenous epoprostenol. We selected open surgery without laparoscopy and Hartmann's operation. After surgery, severe perioperative complications were not detected, and the patient discharged from hospital 17 days after the operation.

Discussion

During surgery under general anesthesia, the mortality rate of PAH is high because of heart and respiratory failure. We planned to switch the PAH treatment from an oral agent to intravenous epoprostenol only in the preoperative period, and selected open surgery. We ligated the inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) below the branch of LCA to avoid marked edema of stoma. Consequently, we could avoid severe intraoperative and postoperative complications.

Conclusions

Controlling PAP using epoprostenol, open surgery, stoma and the ligation level for the IMA and IMV preventing are important to avoid perioperative complications of sigmoid colon cancer complicated by severe PAH.

•

The patient with PAH complicated by MCTD underwent Hartman’s operation for sigmoid colon cancer.

•

Control of PAH by epoprostenol preoperatively is important to prevent perioperative cardiac complications.

•

The level of ligation of the IMA and the LCA is important to avoid severe edema of stoma.

Potential importance of vital capacity for the safety of laparoscopic surgery for colorectal cancer in patients with pulmonary dysfunction

BACKGROUND

We examined the safety of laparoscopic surgery for colorectal cancer (CRC) in patients with pulmonary dysfunction, and evaluated risk factors (RF) for post-operative complications.

METHODS

We defined pulmonary dysfunction as having any diagnosed pulmonary disease with spirometry findings of obstructive or restrictive defects. Clinicopathological factors of 213 patients with pulmonary dysfunction who underwent laparoscopic surgery for CRC at Toranomon Hospital from 1999 to 2016 were evaluated to retrospectively identify RFs for any post-operative complications and major complications, namely post-operative pulmonary complications (PPCs). Examined preoperative factors included age, gender, body mass index, tumour location, smoking history, percentage vital capacity (%VC), forced expiratory volume in 1 s (FEV1.0), a ratio of FEV1.0 to forced vital capacity and American Society of Anesthesiologists physical status grade. Intraoperative factors, such as operative time, blood loss and blood transfusion, were also assessed.

RESULTS

Forty patients (18.8%) developed any complications including PPCs. Multivariate analysis revealed that male, rectal cancer and spirometry findings (both low FEV1.0 (0.8 L) and low %VC (<95)) were RFs (P = 0.026, 0.003 and 0.007, respectively). Six cases (2.8%) developed PPCs. The prevalence of PPCs was higher in patients with both low %VC (<95%) and low FEV1.0 (<0.8 L), with statistical significance (P = 0.006).

CONCLUSION

Our study suggested that not only low FEV1.0 but also low %VC was an important RF for post-operative complications after laparoscopic surgery for CRC.

Randomized Controlled Comparison of Valveless Trocar (AirSeal) vs Standard Insufflator with Ultralow Pneuomoperitoneum During Robotic Prostatectomy

Objective: To compare valveless insufflation (AirSeal^®) with a conventional insufflation system (CIS) during robotic prostatectomy (RP) and the ability to use ultralow pneumoperitoneum at 6 mm Hg with each system as well as comparison of physiologic outcomes and pain scores. Patients and Methods: We conducted a prospective study of 100 patients randomized to AirSeal or CIS during RP. The frequency of need for increasing pneumoperitoneum was assessed as well as arterial blood gases, respiratory/hemodynamic parameters, pain scores, and analgesic requirements. Quality of smoke evacuation and scope cleaning frequency were also measured. Results: All procedures were completed at 6 mm Hg without needing to increase pressures with either insufflator. There were no statistically significant differences in partial pressure of carbon dioxide (PaCO₂), partial pressure of oxygen (PaO₂), HCO₃, pH, carbon dioxide (CO₂) elimination, or end-tidal carbon dioxide pressure (EtCO₂) between groups. The AirSeal group had a lower maximum peritoneal pressure (7.9 vs 9.9 mm Hg, p < 0.001) but without differences in pain scores or analgesics. Surgeon-assessed smoke evacuation was poorer using CIS with more laparoscope cleanings in nonobese patients than with AirSeal (2.1 vs 3.0, p = 0.026). Conclusion: Valveless-trocar insufflation provided more stable pressure but without benefits in physiologic or pain parameters. Previously identified benefits may have been negated by being able to complete all procedures at ultralow pressure with either insufflator, although an expert bedside assistant moderating suction may have contributed to feasibility of maintaining low pressure with CIS. A randomized trial of 6 vs 15 mm Hg is currently underway. The ClinicalTrials.gov Identifier: NCT02114164.

Temporary pacemaker insertion for severe bradycardia following pneumoperitoneum during robot-assisted radical prostatectomy: a case report

Background

Pneumoperitoneum to maintain a constant gas flow to assist various surgeries is known to cause severe bradycardia and has been linked to heart failure;; however, a recent study demonstrated that it is not linked to poorer surgical outcomes; accordingly, it does not require routine preventive measures. Thus, whether there is a link between sudden bradycardia development and surgical procedures is controversial. We report the case of severe bradycardia that occurred along with a complete atrioventricular block (CAVB) during peritoneum creation in robot-assisted radical prostatectomy (RARP).

Case presentation

A 72-year-old man presented at our hospital with prostate cancer and underwent RARP. After pneumoperitoneum, severe bradycardia and CAVB were observed; thus, the surgery was extended by inserting a temporary pacemaker (TPM).

Conclusion

Because of the difficulty in performing emergency procedures in robot-assisted surgeries, the current case is reported to provide an awareness that surgeons should be cautious of the possible complication of bradycardia and CAVB during such operations, and thus should take steps necessary for managing induction of such conditions.

Evaluation of the effects of intraabdominal hypertension on equine central venous pressure

OBJECTIVE

To evaluate the effect of changes in intraabdominal pressure (IAP) on central venous pressure (CVP) in normal horses.

DESIGN

Experimental, in vivo study.

SETTING

University Teaching Hospital.

ANIMALS

Convenience sample of 7 mixed breed horses-5 geldings and 2 mares.

INTERVENTIONS

Pneumoperitoneum was induced in horses under standing sedation with carbon dioxide gas using a laparoscopic insufflator for a total of 60 minutes to simulate clinical elevation in IAP. Pressure was increased stepwise to 20 mm Hg over 30 minutes, and maintained at that pressure for 30 minutes to evaluate the effect of sustained intraabdominal hypertension. CVP was obtained from the cranial vena cava, concurrent with pressure obtained from the peritoneal cavity.

MEASUREMENTS AND MAIN RESULTS

CVP increased as IAP increased up to 12 mm Hg, and declined as IAP increased further. The changes in CVP over time were significantly different (P < 0.03). Repeated measures correlation was positive, and highest, for mean CVP as IAP increased from 0 to 12 mm Hg (r = .70; 95% CI, .43-.85; P < 0.0001). Correlation of mean CVP with insufflation pressure became negative as IAP increased further from 15 to 20 mm Hg (r = -.47; 95% CI, -.66 to -.21; P = 0.0006).

CONCLUSIONS

This report provides preliminary data demonstrating a biphasic trend in equine CVP caused by changes in IAP, similar to that observed in other species. Further investigations are needed to evaluate this trend and to confirm these results in clinical patients.

Evaluation of Gasless Laparoscopy as a Tool for Minimal Access Surgery in Low-to Middle-Income Countries: A Phase II Noninferiority Randomized Controlled Study

Background

Minimal access surgery is not available to most people in rural areas of low-to middle-income countries. This leads to an increase in morbidity and economic loss to the poor and marginalized. Gasless laparoscopic (GAL) procedures are possible in rural areas because they can be performed under spinal anesthesia. In most cases, it does not require the logistics of providing gases for pneumoperitoneum and general anesthesia. The current study compares GAL with conventional laparoscopic (COL) operations for general surgical procedures.

Methods

A single-center, nonblinded randomized controlled trial was conducted to evaluate noninferiority of GAL vs COL at a teaching hospital in New Delhi, India. Patients were allocated into 3 groups and underwent minimal access surgery (cholecystectomies and appendectomies). The procedures were performed by 2 surgeons choosing randomly between GAL and COL. The data were collected by postgraduates and analyzed by a biostatistician.

Results

One hundred patients who met the inclusion criteria were allocated into 2 groups. No significant difference was observed in the mean operating time between the GAL group (52.9 minutes) and the COL group (55 minutes) (p = 0.3). Intraoperative vital signs were better in the GAL group (p < 0.05). The postoperative pain score was slightly higher in the GAL group (p = 0.01); however, it did not require additional analgesics.

Conclusions

No significant differences were found between the 2 groups. GAL can be considered as noninferior compared with COL and has the potential to be adopted in low-resource settings.

Effect of Different Levels of Positive End-Expiratory Pressure (PEEP) on Respiratory Status during Gynecologic Laparoscopy

Background

During gynecologic laparoscopy, pneumoperitoneum, and the position of the patient's head can lead to pathophysiologic changes in cardiovascular and respiratory systems, complicating the management of anesthesia in these patients. One of the strategies for improving the respiratory status of patients undergoing laparoscopy is the use of Positive End-Expiratory Pressure (PEEP).

Objectives

This study aimed to evaluate the effect of different levels of PEEP on the respiratory status of patients undergoing gynecologic laparoscopy.

Methods

In this clinical trial, 60 patients with ASA I were randomly assigned to three groups to control anesthesia: ZEEP (PEEP 0 cmH₂O; 20 cases), PEEP₅ (PEEP 5 cmH₂O; 20 cases), and PEEP₁₀ (PEEP 10 cmH₂O; 20 cases). Respiratory and hemodynamic variables of patients were compared before general anesthetic induction and immediately after CO₂ insufflation at intervals of 5, 10, 20, 30, and 60 min and the end of the operation in the three study groups.

Results

The PEEP application improved pH, PaCO₂, and PaO₂ levels at the end of pneumoperitoneum compared to baseline when compared with the non-use of PEEP (ZEEP group). Also, the frequency of dysrhythmia in the use of PEEP in controlled ventilation was significantly lower in patients with PEEP₁₀ (P < 0.05). The application of PEEP₅ resulted in similar effects to PEEP₁₀ in the levels of respiratory variables.

Conclusions

The PEEP application is associated with improved arterial blood gas in patients with gynecologic laparoscopy. The use of PEEP₁₀ has a greater effect on the improvement of respiratory parameters and complications of pneumoperitoneum.

Severe Intraoperative Bradycardia during Laparoscopic Cholecystectomy due to Rapid Peritoneal Insufflation

Laparoscopy is becoming increasingly popular in gynecological and general surgical operations. There are complications that are inherent to the laparoscopy techniques; amongst them is intraoperative vagal-mediated bradycardia that results from peritoneal stretching. This can occur due to high flow rate of gas during peritoneal insufflation, a practice still happening nowadays. We report a case of a middle-aged hypertensive patient who was undergoing elective laparoscopic cholecystectomy. The patient was assessed more than once preoperatively by the anesthesia team for blood pressure optimization. The patient underwent general anesthesia and developed severe bradycardia immediately after peritoneal insufflation. The management started immediately by stopping the insufflation and deflating the abdomen. Afterwards, atropine was administered intravenously, and CPR was started preemptively according to the ACLS protocol to prevent the patient from progressing into cardiac arrest. She responded to the management and became vitally stable within one minute. After confirming that there was no cardiac or metabolic insult through rapid blood investigations and agreeing that the cause of bradycardia was the rapid insufflation, the surgical team proceeded with the surgery in the same setting using low flow rate of CO₂ to achieve pneumoperitoneum. There were no complications in the second time and the operation was completed smoothly. The patient was extubated and shifted to the postanesthesia care unit to monitor her condition. The patient was stable and conscious and later shifted to the wards and discharged on routine follow-up after confirming that there were no complications in the postoperative follow-up. Therefore, it is important to monitor the flow rate of CO₂ during peritoneal insufflation in laparoscopic surgery as rapid peritoneal stretch can cause severe bradycardia that might progress into cardiac arrest, especially in hypertensive patients. It is also important for the anesthetist to be vigilant and ready to manage such cases.

A prospective comparative study of arterial blood gas parameters in smoker versus non-smoker patients undergoing laparoscopic cholecystectomy

Background and Aims:

Smoking is a risk factor for postoperative pulmonary complications in patients undergoing general anaesthesia. These may get amplified with effects of pneumo-peritoneum and carbon dioxide (CO₂) insufflation during laparoscopic surgeries. Our aim was to compare metabolic and blood gas analysis of smokers versus non-smoker patients during laparoscopic surgeries under general anaesthesia.

Methods:

After permission from institutional review board, 60 patients undergoing laparoscopic cholecystectomy were divided into two groups, smokers and non-smokers (30 each). Along with baseline haemo-dynamic parameters, arterial blood gas sampling was done to assess and compare PCO₂, pH and bicarbonate (HCO₃) values at various time intervals with respect to pneumo-peritoneum creation, between smokers and non smokers.

Results:

Baseline systolic blood pressure was higher and oxygen saturation was significantly lower in smoker group. PCO₂ and end-tidal CO₂ were significantly higher in smokers at all intervals (P < 0.001). pH was significantly lower and HCO₃ higher, in smokers after creation of pneumo-peritoneum. Increase in PCO2 due to pneumo-peritoneum was higher in the smoker group (3.49 ± 8.5) mmHg versus non smoker (0.56 ± 4.86) mmHg, although statistically not significant. Change in pH and HCO₃ was similar between smokers and non-smokers.

Conclusion:

There is a significant difference in baseline arterial blood gas characteristics between smokers and non-smokers. Metabolic effects of CO₂ insufflation and increased intraabdominal pressure appears to be more enhanced in smokers.

Perioperative Anaesthetic Management for Laparoscopic Gastrectomy in a Patient with Coarctation of Aorta

Coarctation of the aorta (CoA) is a congenital condition, usually diagnosed and corrected early in life. Long-term survival with untreated coarctation is uncommon and is associated with high mortality rates in the fifth decade. A patient with CoA may present with problems while undergoing cardiac or non-cardiac surgical procedures which could pose considerable challenges in their anaesthetic management. Hence, the choice of anaesthetic technique plays an important role in determining the perioperative course and postoperative outcome in patients with CoA. This report discusses a case of middle-age man, recently diagnosed with CoA while undergoing a preanaesthetic assessment prior to the surgery for gastric adenocarcinoma involving proximal gastro-oesophageal junction. It highlights the successful anaesthetic management of CoA scheduled for laparoscopic-assisted gastrectomy for gastric adenocarcinoma. Perioperative management goals of the patient included general anaesthesia, epidural analgesia to avoid pain-associated adverse effects and efficient control of blood pressure distal to coarctation to limit the risk of intraoperative morbidity. It also demonstrates a major impact on anaesthesiologists who serve the most important role in managing such patients undergoing surgery with ‘red flag’ features.

The role of anticholinergic medication in the prevention of bradycardia during laparoscopic gynaecological surgery

Bradycardia and cardiac arrest are recognised complications of laparoscopic gynaecological surgery. Anticholinergic agents are indicated in the treatment of perioperative bradyarrhythmia; however, their role in the prevention of bradycardia as a result of insufflation of the peritoneum is less well defined. This article systematically reviewed the literature with respect to the role of anticholinergic agents in the prevention of clinically significant bradyarrhythmia during laparoscopic gynaecological surgery. Eight studies were included for review following an extensive database search. This review highlights the paucity of evidence supporting the prophylactic use of anticholinergic agents in preventing clinically significant bradycardia in women undergoing laparoscopic gynaecological surgery.

Perioperative management of esophageal atresia/tracheo-esophageal fistula: An analysis of data of 101 consecutive patients

BACKGROUND

The perioperative management of esophageal atresia/tracheo-esophageal fistula by open or thoracoscopic approach can be complicated by metabolic derangements. Little is known, however, about the severity of derangements of vital and metabolic parameters in the perioperative period.

AIM

The aim of this study is to describe the perioperative courses of vital and metabolic parameters in 101 consecutive neonates undergoing surgical repair of esophageal atresia type C.

METHOD

In a retrospective cohort study, we extracted all data from the electronic anesthetic and medical charts of patients who underwent esophageal atresia type C repair within 30 days of life (2007-2017). We distinguished three types of surgery: primary open, primary thoracoscopic, and primary thoracoscopic surgery converted to open surgery. Descriptive analysis was applied.

RESULTS

The charts of 117 patients were reviewed: data of 101 were included. The perioperative anesthetic management was not standardized; various methods and medications were used for anesthesia induction and maintenance. Intraoperative blood gas analysis data of 72 patients were available and showed derangements regardless of type of surgery. The median pH-value decreased to 7.21 [IQR 7.14-7.30] and a pH-value below 7.20 was found in 29 patients; in four cases below 7.0, with the lowest value 6.83. The median PaCO₂ reached an upper level of 7.5kPa [IQR 5.8-9.2]; in 13 cases above 10.0kPa, with a peak value of 25.8kPa. These high PaCO₂ levels fluctuated with lowest measured PaCO₂ of median 5.6 [IQR 4.5-6.6], with the lowest value 2.8kPa. The median PaO₂ level reached an upper level of 16.9kPa [IQR 11.8-25.7], in 22 cases above 20.0kPa, with a peak value of 50.0kPa. These high levels fluctuated with lowest measured PaO₂ levels of median 8.3kPa [IQR 6.73-10.5]; the lowest PaO₂ value was 4.7 kPa.

CONCLUSION

Open and thoracoscopic correction of esophageal atresia were associated with periods of severe metabolic derangements. These events need to be taken into account for the evaluation of esophageal atresia (surgical) care and in evaluations of short- and long-term outcomes.

Internal Carotid Artery Blood Flow Response to Anesthesia, Pneumoperitoneum, and Head-up Tilt during Laparoscopic Cholecystectomy

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Little is known about how implementation of pneumoperitoneum and head-up tilt position contributes to general anesthesia-induced decrease in cerebral blood flow in humans. We investigated this question in patients undergoing laparoscopic cholecystectomy, hypothesizing that cardiorespiratory changes during this procedure would reduce cerebral perfusion.

Methods

In a nonrandomized, observational study of 16 patients (American Society of Anesthesiologists physical status I or II) undergoing laparoscopic cholecystectomy, internal carotid artery blood velocity was measured by Doppler ultrasound at four time points: awake, after anesthesia induction, after induction of pneumoperitoneum, and after head-up tilt. Vessel diameter was obtained each time, and internal carotid artery blood flow, the main outcome variable, was calculated. The authors recorded pulse contour estimated mean arterial blood pressure (MAP), heart rate (HR), stroke volume (SV) index, cardiac index, end-tidal carbon dioxide (ETco2), bispectral index, and ventilator settings. Results are medians (95% CI).

Results

Internal carotid artery blood flow decreased upon anesthesia induction from 350 ml/min (273 to 410) to 213 ml/min (175 to 249; −37%, P &lt; 0.001), and tended to decrease further with pneumoperitoneum (178 ml/min [127 to 208], −15%, P = 0.026). Tilt induced no further change (171 ml/min [134 to 205]). ETco2 and bispectral index were unchanged after induction. MAP decreased with anesthesia, from 102 (91 to 108) to 72 (65 to 76) mmHg, and then remained unchanged (Pneumoperitoneum: 70 [63 to 75]; Tilt: 74 [66 to 78]). Cardiac index decreased with anesthesia and with pneumoperitoneum (overall from 3.2 [2.7 to 3.5] to 2.3 [1.9 to 2.5] l · min−1 · m−2); tilt induced no further change (2.1 [1.8 to 2.3]). Multiple regression analysis attributed the fall in internal carotid artery blood flow to reduced cardiac index (both HR and SV index contributing) and MAP (P &lt; 0.001). Vessel diameter also declined (P &lt; 0.01).

Conclusions

During laparoscopic cholecystectomy, internal carotid artery blood flow declined with anesthesia and with pneumoperitoneum, in close association with reductions in cardiac index and MAP. Head-up tilt caused no further reduction. Cardiac output independently affects human cerebral blood flow.

The pathophysiology of complications after laparoscopic colorectal surgery: Role of baroreflex and chemoreflex impairment

INTRODUCTION

The aim of this study was to assess the dynamics of baroreflex sensitivity (BRS) during laparoscopic colorectal surgery in patients with different chemoreflex sensitivity assessed with breath-holding test.

METHODS

The study included 80 patients (mean age, 68 ± 7 years) who underwent routine laparoscopic colorectal surgery under general/epidural anaesthesia. Patients were retrospectively divided into two groups: with normal (breath-holding duration ≥38 s, group N [n = 42]) or high (breath-holding duration <38 s, group H [n = 38]) chemoreflex sensitivity. BRS was initially evaluated after arterial catheter placement before induction, after induction, after pneumoperitoneum, after extubation, and 6 h and 24 h after extubation.

RESULTS

Average BRS was significantly lower in the group with high peripheral chemoreflex sensitivity at all time points. The use of pneumoperitoneum did not significantly influence BRS in either group. After the surgery and 6 h after extubation, no significant changes were observed. After 6 h of the surgery, 11.9% of patients in group N and 57.8% of those in group H (p < 0.05) had severe baroreflex dysfunction (BRS < 3 ms/mmHg). After 24 h, only two patients in group N (vs 13 [34.2%] in group H, p < 0.05) had this dysfunction.

CONCLUSION

Patients with high chemoreflex sensitivity have lower BRS, and it decreases further after anaesthesia induction. The recovery process can take up to 24 h, with an increased risk of perioperative complications in patients with high preoperative chemoreflex sensitivity. The use of pneumoperitoneum does not significantly affect BRS.

Intraoperative serious complications of laparoscopic urological surgeries: a single institute experience of 4,380 procedures

This study aimed to share a single institute experience of 4,380 procedures about in-traoperative serious complications of laparoscopic urological surgeries. From January 2005 to December 2013, 4,380 cases of laparoscopic urological surgeries were recruited in our department. The distribution, incidence, and characteristics of intraoperative serious complications were retrospectively sorted out and analyzed. The surgeries were divided into three groups: very difficult (VD), difficult (D), and easy (E). The com¬plication at Satava class II was defined to be serious. One hundred thirty one cases with intraoperative serious complications were found (3.0%). The incidence of these complications was significantly increased along with the difficulty of the surgeries (P<0.05). The highest morbidity of serious complication belonged to total cystectomy with a ratio of about 17% as compared with other surgeries (P<0.05). The types of these complications included small vascular injury demanding blood transfusion (101 cases, 77.1%), large vascular (venous and artery) injury (16 cases), hypercapnia & acidosis (8 cases), and organ injury (6 cases). The cases of conversion to open surgery were 37 (≤1%). There was no significant difference in the rates of conversion to open surgery among the three groups (P>0.05). The overall tendency of the intraoperative serious complications was decreasing with the time from 2005 to 2013. In conclusion, through standardized training including improving the surgical technique, being familiar with the anatomic relationship, and constantly summarizing the experience and lessons, laparoscopic surgery could be safe and effective with not only minimal invasion but also few complications.

Hemodynamic effects of anesthesia type in patients undergoing laparoscopic transabdominal preperitoneal inguinal hernia repair under spinal vs general anesthesia

PURPOSE

General anesthesia has been used as a standard type of anesthesia for laparoscopic inguinal hernia repair by the transabdominal preperitoneal (TAPP) approach, regional anesthesia being occasionally used in high-risk patients. We had previously designed a controlled randomized trial, comparing spinal with general anesthesia in non-high-risk patients undergoing TAPP inguinal hernia repair. Our results suggested that spinal anesthesia offers some advantages in postoperative pain and additional opioid consumption during the early postoperative period. In the context of this trial, hemodynamic effects of each type of anesthesia are presented.

METHODS

Seventy patients, undergoing elective TAPP inguinal hernia repair were randomized to either general or spinal anesthesia. Data regarding patients' hemodynamic status during the procedure under general or spinal anesthesia were collected, measuring systolic blood pressure (SBP), diastolic blood pressure (SBP), mean arterial pressure (MAP) and heart rate (HR).

RESULTS

There was no significant effect of anesthesia type on systolic, diastolic and mean arterial pressure values after induction of anesthesia and induction of pneumoperitoneum, respectively. There was a significant effect on heart rate values after induction of anesthesia and induction of pneumoperitoneum, respectively.

CONCLUSIONS

Spinal anesthesia is as effective as general anesthesia concerning hemodynamic stability and seems to provide a better result in maintaining hemodynamic stability with fewer fluctuations in blood pressure and mild alterations in heart rate values during TAPP inguinal hernia repair.

Risk Factors for Pulmonary Complications After Laparoscopic Pylorus-preserving Pancreaticoduodenectomy: A Retrospective Observational Analysis

Laparoscopic pylorus-preserving pancreaticoduodenectomy (LPPPD) is less invasive than open pylorus-preserving pancreaticoduodenectomy. However, LPPPD has a long operation time with pneumoperitoneum, which may affect the postoperative pulmonary complications (PPCs). We retrospectively evaluated the incidence of PPCs and their risk factors in LPPPD. In 191 patients who underwent LPPPD, the incidence of PPCs was 28.8% (n=55). Multivariate logistic regression analysis revealed that the risk factors for PPCs were male sex [odds ratio (OR), 2.518; P=0.008], high body mass index (OR, 1.172; P=0.024), and low preoperative serum albumin level (OR, 0.390; P=0.032). Length of hospital stay was significantly longer in the PPC group than in the no-PPC group [17 (14 to 26) vs. 14 (13 to 18) d, P<0.001]. There was no difference in the incidence of surgical complications between the PPC group and the no-PPC group (14.5% vs. 6.6%, P=0.096). These results provide useful information for perioperative pulmonary management in patients undergoing LPPPD.